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Introduction: Posterior circulation stroke (PCS) is often diagnosed late and long-term outcomes have not been described in South India. We wished to study clinical features, long-term outcomes, and independent predictors of the same. Materials and Methods: We conducted a prospective cohort study in PCS patients from January 2014 to May 2017. Morbidity and mortality at discharge, at 3 months and 6 months was studied. Univariate and multivariate analysis of predictors of poor outcome as well as the survival analysis was computed. Results: We recruited 291 PCS during the study period; prevalence of PCS among all strokes was 12.9% in 2014. The mean age was 53.34 years (standard deviation 13.34). Young strokes constituted 28.8%. The common comorbidities were hypertension 72%, diabetes mellitus 52.6%, smoking 38.5%, and dyslipidemia 32.6%. The common presenting symptoms were giddiness 79%, unsteadiness 75.35%, ataxia 56%, motor deficits 48.8% and nausea and vomiting 43%. Most were Ischemic strokes (86.5%); 10.3% gave a history of preceding TIAs. Common arteries involved were posterior cerebral 45%, posterior inferior cerebellar 38%, and basilar artery 19.2%. Among ischemic strokes, large artery atherosclerosis was 50.8%. Dysphagia was seen in 32.6% and sepsis in 19.2%; post stroke pain in 23%, followed by cognition decline in 10.3%. Bad outcome (modifies Rankins score 4-6) was 16.8% at discharge, 16.4% at 1 month, 14.4% at 3 months, and 13.8% at 6 months. Independent predictors of bad outcomes at 6 months were baseline National Institute of Health Stroke Scale (NIHSS) score (Odds ratio [OR] 1615.59 confidence interval [CI] 27.64-94447.7), invasive ventilation (OR 7.77 CI 1.57-38.43), sepsis (OR 17.22 CI 1.45-204.08), and basilar artery involvement (OR 19.98 CI 1.67-238.81). Baseline NIHSS scores between 0 and 5 suggest a good outcome while scores more than 13 suggest a bad outcome at 6 months. At 6 months, half are unemployed. Conclusions: The prevalence, clinical features, and comorbidities were also similar to previous studies. There was good survival at 6 months. NIHSS score is useful in predicting poor outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The effectiveness of gastric lavage in organophosphorus (OP) poisoning has not been established. We assessed the ability of gastric lavage to remove OP insecticides as a preliminary stage in assessing effectiveness. Patients and methods: Organophosphorus poisoning patients presenting within 6 hours were included, irrespective of prior gastric lavage. A nasogastric tube was placed and gastric contents aspirated, followed by at least three cycles of gastric lavage with 200 mL of water. Samples from the initial aspirate and the first three lavage cycles were sent for identification and quantification of the OP compounds. Patients were monitored for complications of gastric lavage. Results: Around 42 patients underwent gastric lavage. Eight (19.0%) patients were excluded from the study because of a lack of analytical standards for ingested compounds. Insecticides were detectable in the lavage samples of 24 of 34 (70.6%) patients. Lipophilic OP compounds were detected in 23 of 24 patients, while no hydrophilic OP compounds could be detected in six patients with reported ingestion of hydrophilic compounds. For chlorpyrifos poisoning (n = 10), only 0.65 mg (SD 1.2) of the estimated ingested amount (n = 5) of 8,600 mg (SD 3,200) was recovered by gastric lavage. The mean proportion of the compound removed by initial gastric aspirate was 79.4% and subsequent three cycles removed 11.5, 6.6, and 2.7%. Conclusion: Lipophilic OP insecticides could be quantified in the stomach contents of OP poisoning patients with the first aspiration or lavage being most effective. The amount removed was very low; hence, routine use of gastric lavage for OP poisoning patients arriving within 6 hours is unlikely to be beneficial. [ABSTRACT FROM AUTHOR]

Background: Bacterial sepsis is associated with significant morbidity and mortality. However, to date, there is no single test that predicts sepsis with reproducible results. We proposed that using a combination of clinical and laboratory parameters and a novel biomarker, plasma neutrophil gelatinase-associated lipocalin (NGAL) may aid in early diagnosis. Method: A prospective cohort study was conducted at a tertiary care center in South India (June 2017 to April 2018) on patients with acute febrile episodes fulfilling the Systemic Inflammatory Response Syndrome (SIRS) criteria. Plasma NGAL and standard clinical and laboratory parameters were collected at the admission. Bacterial sepsis was diagnosed based on blood culture positivity or clinical diagnosis. Clinically relevant plasma NGAL cut-off values were identified using the receive operating characteristic (ROC) curve. Clinically relevant clinical parameters along with plasma NGAL's risk ratios estimated from the multivariable Poisson regression model were rounded and used as weights to create a new scoring tool. Results: Of 100 patients enrolled, 37 had bacterial sepsis. The optimal plasma NGAL cut-off value to predict sepsis was 570 ng/mL [area under the curve (AUC): 0.69]. The NGAL sepsis screening tool consists of the following clinical parameter: diabetes mellitus, the presence of rigors, quick sequential organ failure assessment (qSOFA) >2, a clear focus of infection, and the plasma NGAL >570 ng/mL. A score of <3 ruled out bacterial sepsis and a score >7 were highly suggestive of bacterial sepsis with an interval likelihood ratio (LR) of 7.77. Conclusion: The NGAL sepsis screening tool with a score >7 can be used in the emergency department (ED) to identify bacterial sepsis. [ABSTRACT FROM AUTHOR]

Background and Aim: Hyperglycemia has a significant negative impact on the morbidity and mortality of patients presenting with acute myocardial infarction. This retrospective study was conducted to determine the short-term clinical outcomes (inhospital mortality, cardiogenic shock, acute heart failure, stroke, fatal arrhythmia, and length of stay) of patients with non-ST-elevation myocardial infarction (NSTEMI) patients and to compare the outcomes in NSTEMI patients with and without hyperglycemia on admission. We also wanted to identify the clinical profile and assess the mortality rates in patients with NSTEMI. Materials and Methods: This retrospective study was conducted over 7 years (April 1, 2014-July 31, 2021). The data were extracted from the inpatient medical records and it was analyzed. All adult patients requiring admission in a single medical unit with a diagnosis of NSTEMI were included in the study. Descriptive statistics were obtained for all variables and entered in MS Excel and analyzed with SPSS (SPSS for Windows, version 16.0, Chicago, IL, USA) in the study, and appropriate statistical tests like P value were employed to ascertain the significance. Factors that were significant in univariate analysis were tested by multivariate regression analysis to identify those that independently predicted poor outcomes. Results: Our study cohort consisted of 260 patients, 144 (55.4%) patients had hyperglycemia on admission (admission blood sugar >200 mg/dl), and 116 (44.6%) had normoglycemia. In our cohort, 166 (63.8%) were male. The most common comorbidity was diabetes mellitus 195 (75%) and 134 (68.7%) diabetic patients had hyperglycemia at presentation. The most common clinical outcome was acute heart failure in 225 (86.5%), followed by cardiogenic shock in 110 (42.3%) patients. Fifteen (5.8%) patients had acute cerebrovascular accident during the hospital stay and 39 (15%) had developed fatal arrhythmias. The mean ± standard deviation duration of hospital stay was of 7.09 ± 5.396 days. The mortality in this cohort was 67 (25.8%). The presence of hyperglycemia on admission was not found to have an effect on mortality (odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.34-1.10, P = 0.102); however, the presence of hyperglycemia on admission was an independent predictor of cardiogenic shock (OR: 2.18, 95% CI: 1.069-4.483, P = 0.032), acute heart failure (OR: 3.52, 95% CI: 1.44-8.59, P = 0.006), and acute cerebrovascular accident (OR: 13.76, 95% CI: 1.67-112.0, P = 0.015). Conclusions: The presence of hyperglycemia on admission is an independent predictor of short-term outcomes such as cardiogenic shock, acute heart failure, and acute cerebrovascular accident; however, it does not have an effect on inhospital mortality. NSTEMI is associated with significant mortality. [ABSTRACT FROM AUTHOR]

Background and Objectives: Upper urinary tract infections (UTIs) that require in-patient care can be expensive. Comorbid conditions such as diabetes as well as UTI due to extended-spectrum beta-lactamase (ESBL) producing bacteria may affect costs. The quality of life of patients with this condition has not been described. Methods: This was a cost of illness study that prospectively evaluated patients admitted with upper UTI to a medical ward in a tertiary care hospital. Direct medical and nonmedical costs, indirect costs were collected to make the total cost per admission. Quality of life was assessed using the World Health Organization Quality of Life-BREF score. We also compared costs between those with and without diabetes or ESBL infection. Results: Between March 2016 and July 2017, 92 eligible patients were included in the study. The average age was 55.8 years; two thirds were diabetics. The mean overall cost of a single admission for upper UTI was INR.88, 330.2 (1370.4 USD). This was INR.96, 193.0 (1492.6 USD) and INR.1, 03,154.9 (1600.4 USD) among those with diabetes mellitus and ESBL infection, respectively. The cost was higher among those with diabetes and ESBL than those without; this difference reached statistically significance for the ESBL group. The quality of life was affected in all domains; the psychological being most affected among diabetics and ESBL infected. Conclusions: The mean total cost of admission for an upper UTI in a tertiary care hospital in South India was INR 88,330 (1370.4 USD). This is higher if the patient has diabetes or ESBL organism causing the UTI. Quality of life is clearly reduced especially in the psychological domain. [ABSTRACT FROM AUTHOR]

Byline: Selvin. Mani, Asisha. Mathansingh, Himpreet. Kaur, Ramya. Iyyadurai Sir, Tuberculosis is endemic and remains as a major health concern in developing countries like India. Central nervous system (CNS) tuberculosis [...]

It is unclear if the clinical presentation of poisoning with type 1 and type 2 pyrethroid compounds is different. This study was undertaken to detail the clinical profile and outcome of patients presenting with pyrethroid poisoning and to quantify serum pyrethroid levels. In this prospective study, patients were categorised as poisoning with type 1 pyrethroids or type 2 pyrethroids. Blood samples were sent for compound identification and quantification. Clinical features and outcomes were compared between the two groups. Factors associated with moderate and severe toxicity were explored using univariate logistic regression analysis and presented as odds ratio (OR) and 95% confidence intervals (CI). Type 1 pyrethroids were implicated in 16 patients and type 2 in 43 patients. The incidence of nausea and vomiting (81.2% vs. 81.3%) and tremor (37.5% vs. 32.6%) were similar in type 1 and type 2 poisoning; paraesthesia (6.2% vs. 32.6%, p = 0.04), hypersalivation (0% vs. 20.9%, p = 0.04), seizures (0% vs. 7%, p = 0.29) and depressed sensorium (0% vs. 18.6%, p = 0.03.) were observed more frequently in type 2 pyrethroid poisoning. Pyrethroids were detected in the serum samples of 24 patients; quantification was possible in 22 patients in whom serum levels ranged from 1.1 to 453 μg/ml. The compounds were undetectable in 35 patients. Two patients (lambda-cyhalothrin poisoning and cypermethrin poisoning) required intubation for low sensorium and respiratory distress. The median (interquartile range) duration of hospitalization was 12 (12–24) hours. All patients survived. Factors associated with moderate and severe toxicity included ingestion of a type 2 pyrethroid, lambda-cyhalothrin (OR 7.81, 95%CI 1.55–39.37, p = 0.01) and volume ingested (OR 1.01, 95%CI 1.00–1.02, p = 0.02). Patients with pyrethroid poisoning present predominantly with mild to moderate symptoms. Paraesthesia and hypersalivation are more frequent in type 2 poisoning. A favourable outcome can be expected. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) is a major global health problem, mainly in developing countries. Despite the availability of highly effective first-line antitubercular (ATT) drugs, ATT drug-induced liver injury (ATT DILI) leads to treatment interruption and consequently loss of therapeutic efficacy. Methods: In this prospective cohort study from India, all consecutive patients who met inclusion criteria and started on ATT were included. The incidence, risk factors, and outcome of ATT DILI were determined. A clinical prediction score for ATT DILI was derived. Results: A total of 393 patients were included. The incidence of ATT DILI was 9.7% (95% confidence interval 7%–13.2%). HIV infection, daily regimen, disseminated disease, and chronic liver disease were identified as significant risk factors (P < 0.05) for developing DILI. A prediction score derived from the risk factors showed that a score of >5 could predict DILI with a sensitivity of 74% and a specificity of 67%. All-cause mortality in DILI was 4.7%. Conclusion: The incidence of ATT DILI was 9.7% in our cohort with higher incidence among the patients on daily regimen. The study suggests that the combination of risk factors of extensive TB disease, HIV infection, chronic liver disease, and under nutrition increases the vulnerability to DILI, particularly with daily treatment regimen, emphasizing the role of acquired risk factors in the development of DILI. [ABSTRACT FROM AUTHOR]

Byline: Mathew. Griffith, John. Peter, Gunasekaran. Karthik, Kartik. Ramakrishna, John Antony. Prakash, Rajamanickam. Kalki, George. Varghese, Anugragh. Chrispal, Kishore. Pichamuthu, Ramya. Iyyadurai, Ooriapadickal. Abraham Background and Aims: Scrub typhus, a [...]

Acute febrile encephalopathy is a common syndrome in the tropics with high mortality encountered by emergency physicians. In order to study the aetiology of acute febrile encephalopathy and its mortality and functional outcome over one year, data on all patients >18 years of age with short duration of fever (<14 days) and altered mental status were collected and followed up until one month after discharge. Non-infectious aetiology, found in 29%, portends a poor outcome. [ABSTRACT FROM AUTHOR]

A 68-year-old woman presented with episodes of headache, palpitations, sweating and poorly controlled hypertension for the past 6 years. These symptoms were, at times, associated with micturition, and there were few episodes of micturition syncope as well. She had elevated 24-hour urinary normetanephrine and was found to have a paraganglioma arising from the urinary bladder infiltrating the sigmoid colon. She underwent laparotomy with excision of the bladder paraganglioma, following which her symptoms subsided. Paragangliomas are extra-adrenal catecholamine-producing tumours. Bladder paragangliomas need to be considered when evaluating hypertensive patients with headache, palpitations or syncope related to micturition. [ABSTRACT FROM AUTHOR]

Importance: Rodenticide poisoning is a common occurrence in India. Of the different classes of rodenticides available, yellow phosphorus is considered highly toxic. There are scarce epidemiological data regarding the ingestion of yellow phosphorus in the subcontinent. Objectives: This study aimed to identify the clinical profile of rodenticide-poisoned patients and delineate mortality predictors. Design: Prospective observational study. Setting and participants: Study was conducted at the Department of Internal Medicine, Government Villupuram Medical College and Hospital. All adult inpatients with a history of rodenticide poison exposure were eligible participants. A total of 99 patients completed the study protocol. Main outcome: Survival with or without morbidity and death. Results: In all, 90.91% of patients consumed the paste formulation of rodenticide [yellow phosphorus (67.2%) and yellow phosphorus + zinc phosphide (24%)].The time to resuscitation showed significance to mortality. Survival rate among patients instituted gastric decontamination within 2 hours of exposure (97.87%) was significantly higher than those who were not (84.62%) (p = 0.033). The clinical picture revealed conspicuous absence of signs and symptoms during the first 24 hours. In all, 72.73% (n = 72) manifested with toxidrome after a lag period of 24-36 hours (range 18-72 hours). The dominant clinical manifestations included abdominal pain (52.53%), jaundice (22.21%), coagulopathy (15.15%), encephalopathy (10.10%), shock (10.10%), acute kidney injury (AKI; 7.08%), and multi-organ failure (17.17%). Laboratory data showed elevated aspartate transaminase (AST; 48.47%), alanine aminotransferase (ALT; 49.50%), bilirubin levels (22.21%), metabolic acidosis (10.12%), serum creatinine (7.08%), prothrombin time prolongation (PT/INR; 15.15%), and activated partial thromboplastin time (aPTT) (3.30%). The mortality was 9.1% (n = 9) of which 77.78% (n = 7) died of fulminant hepatic failure. The mean time for death was 4.22 days since exposure (range 2-8 days). Conclusion: Rodenticide poisoning in Southern India is dominated by yellow phosphorus. In this study, we identified delayed resuscitation, jaundice, hepatic encephalopathy, elevation of AST and ALT to >1000 IU/L, metabolic acidosis, and refractory shock as reliable predictors of bad outcome in this patient population. The common mode of death was fulminant hepatic failure. Relevance: Rodenticide poisoning ranks second in mortality hierarchy at our institute, and systematic analysis of this patient population is an urgent need. [ABSTRACT FROM AUTHOR]